Slide 1 Chest Radiology Interpretation: Findings of ... 1 Chest Radiology Interpretation: Findings...
Transcript of Slide 1 Chest Radiology Interpretation: Findings of ... 1 Chest Radiology Interpretation: Findings...
Slide 1 Chest Radiology Interpretation: Findings of Tuberculosis
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Slide 2 Case #1
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Slide 3
Reading the TB CXR
Be systematic!
Start centrally and work outwards
Normal or abnormal
Describe the finding(s)
Consider the significance of the finding(s)
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Slide 4 Mediastinum
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Slide 5 Hila
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Slide 6 Lungs
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Slide 7 Pleura & Diaphragms
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Slide 8 Pleura & Diaphragms
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Slide 9 Pleura & Diaphragms
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Slide 10 Soft tissue & bones
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Slide 11
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Slide 12 Mediastinum
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Slide 13
Lymphoma
AbnormalNormal
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Slide 14
Metastatic disease (unknown primary)
Normal Abnormal
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Slide 15
Lung Cancer
Normal Abnormal
AO
PA
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Slide 16 Heart
<55% thoracic diameter
Technique important
Larger in: AP film
Poor inspiration
Rotation
Children
True enlargement Chamber enlargement
Pericardial effusion
Mass
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Slide 17 Artifactual cardiomegaly
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Slide 18
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Slide 19 End stage rheumatic heart disease
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Slide 20 Pericarditis
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Slide 21 Hila
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Slide 22
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Slide 23 Q1. Pathology in this patient is most
likely to show?
A. Caseating granulomas
B. Non-caseating granulomas
C. Atypical cells with high nuclear/cytoplasmic ratio
D. Fibrosis
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Slide 24
Sarcoidosis
Normal Abnormal
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Slide 25
Pulmonary Hypertension
Normal Abnormal
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Slide 26 Lungs
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Slide 27 Pleura & Diaphragms
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Slide 28 Pleura & Diaphragms
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Slide 29
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Slide 30
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Slide 31
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Slide 32 Q2. Where is this lesion located?
A. Lung
B. Mediastinum
C. Pleura
D. Chest wall
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Slide 33
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Slide 34 Lung Pleura
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Slide 35 Lung Pleura
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Slide 36 Lung Pleura
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Slide 37 Lung Pleura
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Slide 38 TB Empyema
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Slide 39 Don’t forget about the bones
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Slide 40 Case #1
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Slide 41 Case #2
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Slide 42 Q3. What is the primary
abnormality?
A. Mediastinal widening
B. Diffuse lung opacities
C. Pleural effusion
D. Normal
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Slide 43 Inspiration: (≥10 posterior ribs)
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Slide 44
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Slide 45
1st rib
2nd rib3rd rib
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Slide 46 2nd3rd
4th
5th
6th
7th
8th
9th
10th
1st
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Slide 47 Poor inspiration
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Slide 48 Good inspiration
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Slide 49 Rotation
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Slide 50
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Slide 51
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Slide 52 PenetrationIntervertebralDisks
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Slide 53
Over-penetrated
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Slide 54 Case #3
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Slide 55 Q4. What is the most likely diagnosis?
A. Tuberculosis
B. Aspergillosis
C. Malignancy
D. Mycoplasma
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Slide 56 Categories of lung opacities
1. Nodule(s) or mass(es)
2. Alveolar, airspace, consolidation
3. Interstitial (diffuse lines or nodules)
4. Airways (circular or tubular)
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Slide 57 Nodule ≤ 3cm, Mass > 3 cm
2.7 cm3.4 cm
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Slide 58 Consolidation
Confluent opacity
Fluffy around the periphery
Air bronchograms
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Slide 59 ARDS
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Slide 60
Normal Nodular Reticular
Interstitial disease
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Slide 61 Miliary TB
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Slide 62 Idiopathic pulmonary fibrosis
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Slide 63
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Slide 64 Airways disease
Circular
Tubular
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Slide 65
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Slide 66 Tuberculosis
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Slide 67 Case 3
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Slide 68 Questions
Could this be TB?
Is TB the most likely diagnosis?
If so, what form of TB does the radiology suggest?
Is active disease likely or unlikely?
Is TB an unlikely diagnosis?
What are possible alternative diseases to produce the radiographic pattern?
(the answer is always yes!)
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Slide 69 Key points
You must know the classic TB patterns
TB patterns overlap with each other
TB patterns overlap with other diseases
If there is an abnormality, it could be due to TB
But, if it doesn’t fit into a typical TB pattern, it is unlikely to be TB
It’s all about likelihood!
Clinical-radiographic correlation
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Slide 70 Case #3
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Slide 71 Reactivaton TB- radiology
LocationApical/posterior segments upper lobes
Superior segment lower lobes
Isolated anterior disease very unusual
Presence of cavities
Pleural disease
Volume loss/scarring early in disease
Diff dx: fungal, bacterial infections
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Slide 72 Chest Radiology Interpretation: Findings of Tuberculosis (Part 2)
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Slide 73 Is this likely TB?
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Slide 74 Q5. What lobe is involved?
A. Right upper lobe
B. Azygous lobe
C. Right middle lobe
D. Right lower lobe
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Slide 75 Lobar anatomy
Left Lung
LLL
LUL
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Slide 76
Right Lung
RLLRML
RUL
Lobar anatomy
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Slide 77
Right Lung
RLLRML
RUL
Lobar anatomy
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Slide 78 RUL Pneumonia
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Slide 79
Right Lung
RLLRML
RUL
Lobar anatomy
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Slide 80
Right Lung
RLLRML
RUL
Lobar anatomy
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Slide 81
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Slide 82 Silhouette sign
A B A B
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Slide 83 Silhouette sign
A B A B
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Slide 84
Right Lung
RLLRML
RUL
Lobar anatomy
Diaphragm
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Slide 85
RLL
ObscuredDiaphragm
ClearHeartBorder
RLL pneumonia
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Slide 86 ? Which lobe is involved
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Slide 87
Right Lung
RLLRML
RUL
Lobar anatomy
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Slide 88
RML
RML pneumonia
ClearDiaphragm
ObscuredHeartBorder
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Slide 89 ? pneumonia
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Slide 90 ? pneumonia
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Slide 91
Anterior Posterior
Superior
Inferior
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Slide 92 Lateral Viewof the Chest
Heart
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Slide 93 Lateral Viewof the Chest
Spine
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Slide 94 Lateral Viewof the Chest
Diaphragm
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Slide 95 Lateral Viewof the Chest
Diaphragm
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Slide 96 Normal LLL Pneumonia
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Slide 97 Normal Pleural effusion
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Slide 98 Normal Nodule
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Slide 99 Normal Pott’s disease
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Slide 100 Case #4
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Slide 101
Q6. What is the primary abnormality?1. Consolidation
2. Emphysema
3. Airway enlargement
4. Fibrosis
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Slide 102 Abnormal Normal
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Slide 103 Prior reactivation tuberculosis
Upper lobe scarringVolume loss
Retraction of hila superiorly
Band-like (linear) opacities
Architectural distortion
Asymmetric > symmetric
Bronchiectasis
Cystic changes
Diff dx: fungal, sarcoid, pneumoconioses
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Slide 104
Prior TB
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Slide 105
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Slide 106
Warning signs
Consolidation outside areas of fibrosis
Consolidation with cavitation
Lower lobe abnormalities
Non-calcified nodules (ill-defined)
Change from prior CXR
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Slide 107
Reactivation TB
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Slide 108 Case #5
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Slide 109 Q7. What is the likelihood of malignancy?
A. <5%
B. 5-10%
C. 10-20%
D. >20%
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Slide 110
Solitary nodule/mass- the top 5
Granuloma
Hamartoma
Solitary metastasis
Bronchogenic carcinoma
Lots of others
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Slide 111
So you see a nodule on CXR…
1. Look for old films
2. Is diffuse calcification present?
3. Get a CT scan
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Slide 112
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Slide 113
When to get a CT scan?
Questionable CXR findings
Further characterization of CXR findings
Concern for cancer
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Slide 114 Role of CT scan for nodules
1. Attempt to prove they are definitively benignBenign pattern of calcification (diffuse, central,
ring-like, popcorn)
Fat
≥2 years of stability
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Slide 115 Features of benign nodules include:
PopcornRing-like
CentralDiffuse Initial CT
24 monthfollow-up
Benign patterns of calcification
Presenceof fat
Long term stability
Hamartoma
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Slide 116 Hamartoma
.
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Slide 117 Irregular calcification: adenocarcinoma
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Slide 118 Role of CT scan for nodules
1. Attempt to prove they are definitively benignBenign pattern of calcification (diffuse, central,
ring-like, popcorn)
Fat
≥2 years of stability
2. Determine likelihood of nodule being benign or malignant Low likelihood -> CT follow-up
High likelihood -> immediate action (e.g. biopsy)
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Slide 119 Suspicious features of nodules include:
Initial CT
Follow-up
Large size Spiculatedborders
Growth
The size threshold above which malignancy is likely demonstrates geographic variability, depending upon the prevalence of endemic granulomatous infection.
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Slide 120 Size and likelihood of cancer
Swensen. Radiology 2005; 235: 259
0% 1%
15%
81%
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Slide 121 Follow-up recommendationsNodule size Low-risk patient High-risk patients
≤4 mm No follow-up 12 months
>4-6 mm 12 months 6-12 months
18-24 months
6-8 mm 6-12 months
18-24 months
3-6 months
9-12 months
24 months
>8 mm 3 months
9 months
24 months
3 months
9 months
24 months
Fleischner Guidelines. Radiology 2005; 237: 395.
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Slide 122 Old tuberculosis
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Slide 123 Bronchogenic carcinoma
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Slide 124 Case #6
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Slide 125 Case #6Ghonfocus
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Slide 126 Case #6Rankecomplex
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Slide 127
Prior tuberculosis
Mid to lower lung predominance
Can be anywhere
Nodule: Ghon focus
Nodule + lymph node: Ranke complex
Calcification indicative of inactivity
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Slide 128 Case #7
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Slide 129 Q8. What is the most likely diagnosis?
A. Tuberculosis
B. Bacteria
C. Adenovirus
D. Mycoplasma
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Slide 130 Primary tuberculosis
Difficult radiologic diagnosis
Mimics other diseases
FindingsNonspecific consolidation
Nodule
Lymphadenopathy
Cavitation unusual
LAD more common than with 2° TB (particularly kids + HIV)
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Slide 131 Primary tuberculosis
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Slide 132 Primary tuberculosis
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Slide 133 Case #8
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Slide 134 Q9. What is the LEAST likely diagnosis?
A. Tuberculosis
B. Hypersensitivity pneumonitis
C. Fungal infection
D. Sarcoidosis
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Slide 135
Miliary pattern CXR
Miliary tuberculosis
Fungal infection (histo, cocci, blasto)
Metastases
Sarcoidosis
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Slide 136
Miliary tuberculosis
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Slide 137
Miliary TB
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Slide 138
Sarcoidosis
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Slide 139
Metastases
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Slide 140 Case #10
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Slide 141 Pleural + pericardial disease
Primary or secondary
May be only manifestation in 1° TB
Empyema more common in secondary
Adults >> kids
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Slide 142 Suspected pleural effusion
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Slide 143
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Slide 144 Case #11
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Slide 145 Q10. What is the primary
abnormality?
A. Lymphadenopathy
B. Pericardial effusion
C. Lytic bony lesion
D. Normal
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Slide 146 Case #11
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Slide 147
Lymphoma
Leukemia
Germ cell tumor
Bacterial mediastinitis
Fungal infection
Tuberculosis
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Slide 148 Lymphadenopathy with TB
Kids >> adults
Primary >> secondary
Asymmetric (right > left)
Most common locationsHilar
Right paratracheal
Necrosis very common
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Slide 149
TB lymphadenitis
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Slide 150 Case #12
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Slide 151
heart <65% thoracic diameter
thymus
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Slide 152 Conclusions
Be systematic when reading CXR
Typical TB patterns
Mimics of TB
Get a CT scan when appropriate
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Slide 153
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